Home Health & Hospice Week

Ignoring ADRs pretty much guarantees more review, expert warns.

The consequences for not performing well under Targeted Probe & Educate review can be harsh - and eventually fatal to your agency. Follow this expert advice to avoid getting caught up in a deadly TPE cycle.

1. Start with the basics: Respond. HHH Medicare Administrative Contractor CGS has reported that two of the 15 home health agencies that completed TPE review in the first six months of the program did not respond to Additional Development Requests.

"Respond timely to the probe," urges Joe Osentoski with QIRT in Troy, Michigan. The TPE burden can be heavy, with each round requiring responses to 20 to 40 ADR requests. But "it is really inexcusable these days for providers to not even respond to the ADR requests," Osentoski says. "Nonresponse to a record request virtually guarantees further probes and review."

2. Avoid outdated F2F procedures. Many home health agencies may be caught in an old face-to-face physician encounter rut, where they use a form only, believes consultant J'non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama. Instead, F2F information must be included on the Plan of Care and the agency must acquire the physician's visit note.

3. Tighten up F2F review process. Don't let F2F requirements slip through the cracks. Create "a face-to-face gatekeeper who knows all the requirements for timing, signature, content, and certification," Osentoski recommends. That person should review "100 percent of new admissions at time of admission," he says.

4. Use your F2F time. Don't give up if the F2F requirements aren't fulfilled at first. "Understand that if the face-to-face requirements are not all present [at admission], that agencies can use that 30-day window after admission to get a valid encounter in the record," Osentoski advises.

5. Empower your supervisors on therapy. Lack of medical necessity documentation for therapy is a common problem found by MACs in TPE, and one that Griffin sees often. HHA administrators, who are most often nurses, have been hesitant to challenge therapists when they say patients need more therapy, she says. That's because the nurse administrators aren't on sure footing with their understanding of therapy requirements.

Do this: Educate "supervising staff on what is considered reasonable and necessary, so they can oversee the documentation also," Griffin counsels.

6. Get familiar with therapy LCD. You can learn the ins and outs of therapy coverage and documentation requirements in Local Coverage Determinations from your HHH MAC. "Review and follow all applicable therapy LCDs," Osentoski exhorts. "This is the best defense against therapy documentation denials."

7. Pore over recerts with a critical eye. Claims for recertified episodes are particularly vulnerable to denials. "Initiate a robust recertification evaluation process," Osentoski urges. "This applies to therapy reassessments, identifying a current status and a valid reason to continue service into a following episode. There must be specific reasons to continue care: a change in condition, a new treatment, an unplanned event in the prior episode that limited home health achieving its goals.

Red flag: "Never recertify to monitor a condition," Osentoski emphasizes.